NURN 155 Assessment: Perfusion

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Questions and Answers

What is the primary function of perfusion in the human body?

Debating oxygen levels in the lungs

Producing blood cells in the bone marrow

Maintaining body temperature

Delivering nutrients and oxygen to cells while removing waste (correct)

Which of the following is NOT a modifiable risk factor for perfusion disturbances?

Family history of diabetes (correct)

Hypertension

Tobacco use

Obesity

Which symptom is commonly associated with perfusion disturbances?

Increased appetite

Cyanosis or pallor (correct)

Chronic nasal congestion

Frequent urination

In an auscultation examination, which heart sounds are considered normal?

S1 and S2 Signup and view all the answers

What is the correct location to palpate the apical impulse or point of maximal impulse (PMI)?

4th-5th intercostal space, midclavicular line Signup and view all the answers

Which of the following best describes an abnormal finding during a physical assessment for perfusion?

Presence of murmurs or dysrhythmias Signup and view all the answers

Which health conditions are linked to increased modifiable risk factors for perfusion issues?

Metabolic syndrome and psychological states Signup and view all the answers

What is indicated by a jugular venous distension (JVD) during assessment?

Fluid volume overload Signup and view all the answers

Which position should a patient be in to properly assess for pericardial friction rub?

Sitting upright and leaning forward Signup and view all the answers

During a patient health interview, which statement indicates a potential risk factor for perfusion disorders?

I have experienced leg pain or cramps occasionally Signup and view all the answers

Which factor does NOT contribute to assessing the integrity of the peripheral vascular system?

Rate of the carotid pulse Signup and view all the answers

What does a carotid bruit typically indicate during an examination?

Narrowed blood vessel creating turbulence Signup and view all the answers

When assessing pulse quality, what does a rating of '0' signify?

Absent pulse, not palpable Signup and view all the answers

What is considered a normal capillary refill time when assessing perfusion?

1-2 seconds Signup and view all the answers

What does it indicate if the patient's skin color appears cyanotic during assessment?

Possible respiratory distress Signup and view all the answers

In the assessment of pulse, what does a rating of '3+' denote?

Full pulse, increased Signup and view all the answers

What characterizes brawny edema compared to pitting edema?

It involves chronic discoloration and does not pit. Signup and view all the answers

What is the primary function of thromboembolic devices (TEDS)?

To aid in maintaining external pressure for venous return. Signup and view all the answers

What signifies an elevated level of B-type natriuretic peptide (BNP)?

It marks heart failure. Signup and view all the answers

What is the primary function of sequential compression stockings (SCDs)?

To alternately inflate and deflate to increase venous return. Signup and view all the answers

Which of the following best describes the use of a Doppler ultrasonic stethoscope?

To detect variations in peripheral pulses. Signup and view all the answers

Study Notes

Objectives

Define perfusion as the blood flow through arteries and capillaries that delivers nutrients and oxygen while removing cellular waste.
Identify modifiable risk factors for perfusion issues: elevated serum lipids, hypertension, tobacco use, physical inactivity, obesity, diabetes, metabolic syndrome, psychological states, and high stress.
Recognize signs and symptoms of perfusion disturbances: dyspnea, cough, fatigue, cyanosis, pallor, and edema.
Consider personal and family cardiac history impacting patient treatment including conditions like hypertension, congenital heart disease, and history of sudden death.

Assessment Components

Evaluate cognition, vital signs, heart sounds, apical pulse, peripheral pulses, and subjective data through health interviews.
Inspect and palpate for jugular venous distension (JVD) as a marker of fluid volume status.

Heart Sounds

Auscultation techniques: use bell for low-pitched sounds and diaphragm for high-pitched sounds.
Normal heart sounds: S1 and S2; may also hear extra sounds (S3, S4), dysrhythmias, and murmurs.

Inspection & Palpation

Locate apical impulse (point of maximal impulse) at the 4th-5th intercostal space along the midclavicular line.
Observe for carotid bruits which indicate narrowed blood vessels.

Pulses

Assess pulse characteristics: rate, regularity, and quality ranging from 0 (absent) to 4 (bounding).
Perform capillary refill test by blanching nail beds; normal time for color return is 1-2 seconds.

Edema Types

Pitting Edema: leaves an indentation upon applying pressure.
Brawny Edema: chronic with discoloration, no pitting, remains swollen despite treatment.

Doppler Assessment

Use a Doppler ultrasound to detect weak peripheral pulses and measure low blood pressure, enhancing the ability to hear pulsatile sounds.

Device Utilization

TED Hose: Thromboembolic devices used for promoting venous return via external pressure.
SCDs (Sequential Compression Devices): alternately inflate and deflate to reduce venous stasis.

Laboratory Studies

B-Type Natriuretic Peptide (BNP): neurohormone indicating heart failure when elevated (normal < 100 pg/mL).
Prothrombin Time (PT) normal range: 11.0-13.0 seconds.
International Normalized Ratio (INR) is a key lab value for assessing coagulation.

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Description

This quiz evaluates your understanding of perfusion, including its definition, modifiable risk factors, and assessment findings. You will explore key considerations for patients experiencing perfusion disturbances. Test your knowledge and enhance your clinical skills related to perfusion assessment.